I. Current status of breast cancer treatment
In China, the health burden of cancer is growing year by year, with more than 1.6 million people diagnosed with cancer and 1.2 million deaths due to cancer each year. As in most other countries, breast cancer is the most common cancer among Chinese women; it accounts for 12.2% of new cases and 9.6% of deaths worldwide each year. China’s increasing global “contribution” is largely attributed to its rising socioeconomic status and specific fertility patterns.
Academician Tang Zhaoyu: Cancer is not the end of life. The prevention of cancer recurrence and metastasis is a lifelong priority for cancer patients and should not be taken lightly. According to the latest data released by Shanghai Center for Disease Prevention and Control, there are currently 250,000 cancer patients in Shanghai, more than 1 in every 100 people, and cancer has become the biggest killer that threatens our quality of life. In addition to the super high cancer rate, another point worth noting is the super high metastasis and recurrence rate.
The ultimate goal of cancer treatment is survival, and living is victory. Therefore, for cancer treatment, there is a need to change the mindset: it should eliminate and transform at the same time. In order to learn to survive with tumor, we should learn “double prevention”, that is, to prevent metastasis and recurrence of cancer, and to destroy cancer cells and at the same time, we should pay attention to transforming residual cancer and organism, so that cancer cells have nowhere to live. In China, 85% of cancer patients die not in the treatment period but in the recovery period, even when there is a ray of hope for life, which is the patient’s greatest fear of recurrence and metastasis, and is also the realistic support for the existence of the “double prevention” theory.
Definition and status of breast cancer survivors
Breast cancer survivor is defined as a cancer patient who has been able to maintain a normal life since the date of cancer diagnosis, and the concept of normal life includes the patient’s family, friends and caregivers. Breast cancer survivors, including long-term survivors, are in poorer health than the general population without cancer, independent of the length of cancer diagnosis. In addition to an increased risk of recurrence and second tumors, cancer survivors have high non-cancer mortality rates, with cardiopulmonary disease being the most common cause.
The American Cancer Society adds details and figures from their latest study in “CancerTreatment and SurvivorshipFacts & Figures”. Anyone who survives a cancer diagnosis is defined as a “cancer survivor. The report also predicts that the number of people in the United States who have survived cancer will rise by one-third over the next 10 years, reaching approximately 18 million by 2022. One reason for this increase is due to an increase in the population and, on the other hand, an increase in the number of older adults due to the dramatic increase in cancer incidence with increasing age. While overall the number of cancer patients is decreasing, the number of cancer survivors is increasing. Almost half of those over 70 years of age in the United States are cancer survivors, but this figure is only 5% among those under 40 years of age.
III. Lifestyle interventions to prevent or reduce recurrence in breast cancer survivors
Cancer survivors have an increased risk of developing a second tumor compared to the general population because more than 35% of cancer survivors have lifestyles such as smoking and alcohol consumption. Other lifestyle risk factors such as excess weight and low physical activity also increase the risk of developing second tumors. It is an accepted fact worldwide that unhealthy lifestyle habits can lead to tumors. But can cancer patients gain survival benefits by living a healthy life and what does it mean to live a healthy life? D. in the United States recently published an article in J. Pers. Med on the impact of lifestyle on the quality of life and prognosis of cancer survivors, making it clear that a healthy lifestyle is an important component of treatment for cancer survivors and has a profound impact on the long-term health of patients.
Survivorship treatment focuses on ensuring that patients have a healthy and beneficial life after cancer treatment, including physical, psychological and socioeconomic topics. There are four essential elements of survivorship treatment: monitoring for cancer recurrence and second tumors, monitoring for the late medical and psychological effects of cancer and its treatment; prevention of cancer recurrence and second tumors and the late effects of cancer treatment; interventions for outcomes resulting from cancer and its treatment; and increased therapeutic collaboration between primary care physicians and oncologists. Each element is important to ensure that cancer survivors receive comprehensive care.
As long-term survivorship continues to increase, a large body of literature describes the impact of lifestyle on survivorship. Evidence from epidemiological studies and interventional studies suggests that lifestyle has an ameliorative effect on side effects of certain cancer treatments, as well as on disease recurrence and improves overall health outcomes. Lifestyle interventions are a very important aspect of survival treatment, and cohort studies have shown that for certain types of tumors, physical activity or a healthy diet can affect quality of life, disease-specific outcomes and overall health outcomes in survivors.
Lifestyle interventions.
Weight loss
Being overweight is a risk factor for many cancers and is most strongly associated with breast, colorectal, prostate, esophageal, and pancreatic cancers. Obesity also increases the risk of liver, cervical, ovarian, non-Hodgkin’s lymphoma, multiple myeloma, and aggressive prostate cancer. The most research has been done on the impact of weight gain on disease in women treated for breast cancer, with increased patient weight associated with higher cancer-specific and all-cause mortality rates. Possible reasons for increased mortality include reduced chemotherapy doses adjusted for body weight and selection of less aggressive treatments because of obesity. However, there are also trial data showing increased mortality if adequate chemotherapy is given based solely on body weight, and the reasons for this need to be further explored.
1. Diets and dietary supplements of cancer survivors
Many studies have examined the dietary habits of cancer survivors and the effect of diet on cancer-related outcomes and overall mortality, and similar to the general population, reduced fat and energy intake is associated with a lower risk of recurrence and death. Studies have shown that multivitamin supplementation in early-stage breast cancer patients does not improve the risk of recurrence, cancer-specific mortality or overall mortality, and this also applies to colon and lung cancers, with one study even showing an 18 percent increase in lung cancer incidence in patients supplemented with betacarotene. Healthy habits are important for cancer prevention, and cancer survivors should improve their lifestyle and habits, including their diet. Nutritional assessment should be part of the overall treatment plan, starting at the time of diagnosis and continuing after treatment is completed.
The NCCN and AICR have published guidelines or recommendations on nutrition and diet for cancer survivors, recommending that cancer survivors should get their nutrition needs through food rather than through dietary supplements. The dietary pattern for cancer survivors should be rich in vegetables, fruits, and whole grains, with at least 2.5 cups of vegetables and fruits per day.
The AICR and NCCN recommend a diet rich in vegetables, fruits, and whole grains, low in animal protein, and a diet that is low in fat, preferably from plant and fish sources, and low in red meat.
The ACS and NCCN do not advocate the use of dietary supplements unless there is a clear deficiency of a substance or a deficiency in dietary intake. the ACS supports multivitamin supplementation for cancer survivors who cannot meet their nutritional needs through diet after cancer treatment. Due to the lack of clear benefit, vitamin D supplementation is only indicated for bone health or other general health needs.
2. Physical activity for cancer survivors
Physical activity and exercise have a positive impact on the quality of life of cancer survivors, affecting patients’ fear of recurrence, self-esteem, good mood, sexual desire, sleep disturbance, social functioning, anxiety, weakness, and pain. Studies have shown that physical activity and exercise reduce cancer-specific and all-cause mortality in early-stage breast, prostate and colorectal cancers, but up to 66% of cancer survivors do not meet physical activity standards, and those who do have a better quality of life. Moderate to vigorous activity, such as three hours of walking, bicycling or swimming per week, reduces all-cause and cancer-specific mortality in postmenopausal breast cancer patients. Additional meta-analyses have shown that physical activity also reduces breast cancer recurrence.
In addition to aerobic physical activity, antagonistic training can be beneficial for some cancer survivors. Previously, when breast cancer survivors developed lymphedema or were at high risk for lymphedema, patients were often asked to minimize the use of the affected limb and avoid weight bearing in order to reduce lymphedema or reduce the risk of lymphedema. However, the PAL study showed that breast cancer survivors with lymphedema could reduce edema symptoms and increase strength in the affected limb with progressive weight training. In breast cancer survivors at risk for lymphedema, progressively increasing load training did not increase the incidence of lymphedema. Therefore, antagonist training under proper supervision is safe and potentially beneficial.
Physical activity may also improve treatment-related side effects. For example, weight training, especially antagonistic training, is very beneficial for bone mineral density in both premenopausal and postmenopausal women and can also reverse up to 1% of bone loss per year in the vertebrae and femoral neck. This is particularly important for cancer survivors on endocrine therapy, who are at significantly increased risk of osteoporosis. Aromatase inhibitors (AI) can induce arthralgia, which is a major reason for poor compliance with adjuvant endocrine therapy in breast cancer survivors. Prospective studies have demonstrated that physical activity can improve AI-induced arthralgia and is an inexpensive way to increase adherence to treatment.
Cancer survivors with less limited physical activity should be guided by standard guidelines. The ACS, NCCN and ACSM guidelines recommend that cancer survivors without significant motor limitations should engage in at least 150 minutes of moderate-intensity exercise or at least 75 minutes of vigorous exercise per week, with a balanced distribution of exercise time. The duration of exercise should be evenly distributed, in addition to 2-3 sessions of antagonistic or strength training per week. Most survivors do not meet the guidelines for casual exercise, which requires that short- and long-term goals for physical activity be set (by the physician), including gradual increases in physical activity and changes in the type of activity.
3. Smoking cessation and alcohol avoidance
The general population can benefit from quitting smoking, and the benefits are particularly high for cancer survivors, where smoking has a negative impact on cancer outcomes. Smoking cessation improves cancer and overall health outcomes, so the NCCN Survivorship Guidelines recommend that all cancer survivors should quit smoking as a routine treatment measure. Recent research published by U.S. researchers shows that for postmenopausal women with breast cancer, drinking alcohol three to four times a week significantly increases the rate of breast cancer recurrence. The higher the amount of alcohol consumed, the higher the risk of breast cancer recurrence. Considering that alcohol can increase the level of estrogen in the body, which is prone to breast cancer. Therefore, post-breast cancer patients should not drink alcohol regularly. Alcohol can trigger breast cancer, and if we want to prevent breast cancer recurrence, we have to start by eliminating alcohol. For the general population, the evidence clearly and consistently shows that moderate alcohol consumption (1-2 times a day) reduces the risk of cardiovascular disease. For breast cancer patients, the effects of moderate alcoholic beverage consumption are complex and require consideration of both the risk of recurrence and second primary breast cancer and the cardiovascular disease benefit.
There is substantial evidence that lifestyle can influence cancer-related outcomes, both in terms of quality of life and prognosis. Obesity, poor diet, under-activity, and persistent smoking have adverse effects on cancer survivors, and lifestyle interventions can ameliorate the adverse effects. However, specific patterns of physical activity require further study, in addition to assessing the biological mechanisms by which lifestyle modifications and health behaviors affect cancer outcomes.
Patients are more receptive to lifestyle changes when they realize that cancer can be modified to some extent and also have relevant recommendations from their physicians. Therefore, lifestyle recommendations are a very important part of treatment for cancer survivors and should be incorporated into the overall treatment plan. This will have a profound impact on the long-term health outcomes of patients.
IV. Five recommendations to overcome fear of recurrence in breast cancer patients
For cancer survivors, it is only natural to worry about the return of cancer. According to a 2013 survey published in PsychoOncology, about 33%-96% of cancer survivors suffer from the persistent fear of cancer recurrence, which is the most common obsession of survivors.
1. Take a few slow, deep breaths with your mind and full attention.
Concentration and slow, deep breathing can calm the nervous system, reverse the release of stress hormones that damage cells, and stop the accompanying fearful thoughts. In the temporary pause created by slow, deep breathing, one can choose to focus one’s thoughts on a particular place instead of allowing fear to grow everywhere.
2. The practice of returning to the present moment.
Practice getting your attention back to the here and now. A simple and effective way is to pay attention to the information input from all the senses: what is seen, heard, touched, smelled and tasted at this moment. The mechanism by which this exercise works is that people cannot focus on the present and the future at the same time. In times of fear, future scenarios occupy the mind, while conversely, the senses are occupied with the details of the present moment. Fear naturally slips out of one’s focus as one concentrates on the present moment, on what is happening in daily life.
3. Develop a regular practice of gratitude.
Notice that today, right now, everything is going well, and be grateful for that well. Gratitude has the power to replace fear because there is no way for people to feel both gratitude and fear – it can only be one or the other. Gratitude and fear create two opposite physiological states: fear produces tension hormones, yet gratitude recalls the production of tension hormones, and gratitude is associated with the production of feel-good hormones, such as oxytocin. By mastering this ability to produce gratitude at any time, one has a powerful tool to remove fear and change back to oneself. However, while most people can feel gratitude when they are safe, it is much more difficult when there is fear involved. Developing a daily gratitude practice, such as writing down five things you are grateful for before you go to bed each day, will make it easier to feel grateful when the specter of cancer recurrence looms.
4. Embrace preventive health practices.
People are not completely helpless to prevent cancer from coming back. There are many things that can help survivors build a stronger body to fight cancer: drinking enough pure water, choosing nutritious foods, developing good exercise habits, and much, much more. Each of these actions will lead to more strength and improved fitness, as well as a silent declaration that “I love my life and I am trying to live it well and healthy. With such a belief, fear will shrink for lack of attention.
5. Remember: Today is the tomorrow you feared yesterday.
Today isn’t that scary, is it? Many of the things we have feared never happened. Why not use your energy to think about what good things will happen tomorrow?
Warm tip: If you are a cancer survivor and you want to do your best to reduce the occurrence of cancer recurrence or other tumor tumors, then you should maintain a healthy diet, do more exercise to maintain a healthy weight. Doing more physical exercise, eating a healthy diet and maintaining a healthy weight can also reduce the probability of cancer recurrence in cancer survivors. These same lifestyle factors will improve the disease-free survival rate of cancer survivors after a cancer diagnosis. Obesity, lack of exercise, and excessive alcohol intake are all risk factors for cancer development that we should focus on. To conquer fear is to conquer yourself.